Gilmar Geraldo dos Santos

Randomized comparative study of radial artery and right gastroepiploic artery in composite arterial graft for CABG.

OBJECTIVES Arterial grafts have been used to achieve better long-term results and improve graft patency in coronary artery bypass grafting. Composite graft was proposed to overcome inconveniences of proximal anastomoses to the aorta and increase the use and surgical options of arterial grafts. However, lack of prospective randomized studies with this kind of grafts is evident. We compare the results of composite Y-grafts of the radial artery (RA) and the right gastroepiploic artery (RGEA) proximally anastomosed to the left internal thoracic artery (LITA) for CABG, evaluated through angiography, in a prospective randomized study. METHODS Between August 1998 and November 1999, 60 patients were randomly divided into two groups: group I (GI) received RGEA graft and group II (GII), RA graft. LITA was used to graft the left anterior descending artery and RGEA or RA was placed to obtuse marginal or first diagonal branch. The right coronary artery branches was grafted with saphenous vein graft (SVG) when necessary. All coronary arteries receiving arterial grafts had > or =75% proximal stenosis and diameter > or =1.5 mm. RESULTS GI and GII preoperative data were similar, 63 distal anastomoses were performed with the LITA, 32 with the RA and 32 with the RGEA. There were two perioperative deaths (3.3%), one in each group, none related to cardiac causes. Four (6.6%) q-wave myocardial infarctions were found and two (3.3%) patients showed low cardiac output syndrome. Angiography was performed in all surviving patients from the 8th to 15th postoperative day and showed a patency rate of 96.5% (56/58) for LITA, 89.6% (26/29) for RA and 68.9% (20/29) for RGEA, with a statistically significant difference between RGEA and RA (P=0.025). CONCLUSIONS Radial artery had better early results than right gastroepiploic artery. Use of the LITA as inflow graft seems not to affect its good patency. Use of the RGEA as composite graft should not be encouraged. Long-term follow-up with objective investigation and randomized trials is required to confirm better results of composite conduits.

Unusual abdominal tumors with intracardiac extension. Two cases with successful surgical resection.

Abdominal tumors that can grow through vascular lumen and spread to the right heart are rare. Although these tumors have different histologic aspects, they may cause similar abdominal and cardiac symptoms and are a serious risk factor for pulmonary embolism and sudden death when they reach the right atrium and tricuspid valve. The best treatment is radical surgical resection of the entire tumor using cardiopulmonary bypass with or without deep hypothermia and total circulatory arrest. We report the cases of two patients, the first with leiomyosarcoma of the inferior vena cava and the other with intravenous leiomyomatosis of the uterus that showed intravascular growth up to right atrium and ventricle, who underwent successful radical resection in a one-stage procedure with the use of cardiopulmonary bypass. We discuss the clinical and histologic aspects and imaging diagnosis and review the literature.

Cirurgia da valva aórtica: estudo prospectivo e randomizado da miniesternotomia versus cirurgia convencional

Objetivos: A cirurgia minimamente invasiva objetiva, atraves de menor trauma cirurgico no paciente, recuperacao mais rapida, menor tempo de internacao em unidade de terapia intensiva e hospitalar, assim como menor dor e custo hospitalar. Atraves de estudo clinico prospectivo e randomizado, visamos avaliar as vantagens da cirurgia minimamente invasiva da valva aortica sobre a cirurgia convencional. Material e Metodos: Foram 40 pacientes consecutivos, portadores de doenca da valva aortica, com idade inferior a 80 anos, submetidos a primeira cirurgia, de forma prospectiva, randomizados por computador em 2 grupos (miniesternotomia em L invertido e de forma convencional), no periodo de junho de 1997 a agosto de 1998. Todos os pacientes foram operados seguindo-se protocolos cirurgicos pre estabelecidos, Ambos os grupos eram clinicamente semediantes. As seguintes variaveis foram avaliadas: tamanho da incisao, tempos de isquemia, de circulacao extracorporea e de cirurgia, tempo de internacao hospitalar e em UTI, tempo de extubacao, sangramento, dor e mortalidade. Os dados foram submetidos a analise estatistica pelos testes T de Student, de Mann Whitney e o Exato de Fisher. Resultados: O grupo submetido a cirurgia minimamente invasiva para a troca da valva aortica apresentou tempos de isquemia e de circulacao extracorporea significativamente maiores que o grupo convencional (respectivamente p=0,006 e p=0,041). O tamanho da incisao foi significativamente menor (p<0,001). As demais variaveis analisadas nao apresentaram diferencas estatisticamente significativas. Conclusoes: Observou-se efeito cosmetico melhor devido a incisao menor pela tecnica da miniesternotomia e menores tempos de isquemia e circulacao extracorporea atraves da cirurgia convencional. As demais variaveis estudadas apresentaram resultados semelhantes para ambos os grupos.

Primary schwannoma of the right atrium: successful surgical resection

Nonmyxomatous primary cardiac tumors are rare. Primary neurogenic tumors of the heart originating in the nerve sheath are extremely uncommon, and to date, 10 cases of neurilemomas, or schwannomas, have been reported. We report the case of a patient with a right atrial tumor who underwent a successful resection; histological examination revealed a benign primary schwannoma of the heart. […] Primary schwannoma of the right atrium: successful surgical resection

Fibrilação atrial e flutter após operação de revascularização do miocárdio: fatores de risco e resultados

OBJECTIVE: The aim of this study was to determine the overall incidence and predictors of atrial fibrillation and flutter (AFF) following CABG, as well as the influence of these arrhythmia on the hospital length of stay. MATERIAL AND METHODS: Two hundred and seventy-five patients, who had undergone coronary artery bypass graft (CABG) surgery at the Beneficencia Portuguesa Hospital in Sao Paulo, had their data collected and analyzed. The age range was from 26 to 83 years old with mean age of 58.7 and standard deviation of 9.5 years. One hundred and ninety six patients (71.3%) were male. RESULTS: The outcomes of this analysis were: the overall incidence of postoperative AFF was 16.4%, with the peak rate in the second and third postoperative days. Advanced age (p < 0.0001; 95% confidence interval [CI], 3, 140 to 9.046 ); male sex (p = 0.0126; odds ratio [OR], 3.022; relative risk = 2.380; 95% CI 1.103 to 5,135) and a history of AFF (p = 0.0235, OR = 15.54, relative risk = 1.023, 95% CI 0.6225 to 387.9) were identified as independent predictors of postoperative AFF. Those patients with postoperative AFF remained an average of 36 hours longer in the intensive care unit and 4.8 days longer in the ward when compared with patients without AFF. CONCLUSIONS: The AFF are very common arrhythmia after CABG and have a significant effect on both intensive care unit and overall hospital length of stay.

Espasmo coronário no pós-operatório de cirurgia de revascularização do miocárdio: relato de caso e revisão concisa da literatura

Coronary artery spasms may occur as a serious complication during the trans-operative and immediate postoperative periods of coronary artery bypass surgery (CABS). The small number of cases reported is responsible for making it difficult not only to choose an adequate treatment but also to determine risk factors that might be responsible for its incidence. Coronary artery spasms have a multifactorial character, sudden appearance and must be part of the differential diagnosis of acute myocardial infarction and low output syndrome among patients submitted to heart surgery. We describe a case of a patient submitted to CABS with extracorporeal circulation who presented electrocardiographic alterations suggesting acute myocardial infarction during the immediate postoperative period but was diagnosed as having coronary artery spasms evidenced by a coronary catheterism performed afterwards. The patient was successfully treated with intracoronary vasodilators with good evolution over the short and medium terms.

Miniesternotomia para a cirurgia da valva aórtica: experiência inicial

We present our initial experience with minimally invasive surgery for the treatment of aortic valve diseases, through a minithoracotomy. From June to November of 1997, 12 patients underwent aortic valve replacement. The surgical technique utilized was ministernotomy from the notch to the fourth right intercostal space. There was no mortality, nor reoperation. There was necessity of complete sternotomy in one case because of difficult of leaving CPB. Late evolution was possible in 91.6% of the cases and they are all free of symptons.

Tratamento cirúrgico dos aneurismas de ventrículo esquerdo com reconstrução geométrica: aspectos cirúrgicos e resultados imediatos

Os resultados imediatos de 79 pacientes operados num periodo de sete anos para tratamento cirurgico de aneurisma de ventriculo esquerdo com a tecnica de reconstrucao geometrica circular sao analisados. A indicacao cirurgica mais frequente foi a insuficiencia cardiaca congestiva (78,4%), isolada (25,3%) ou associada a insuficiencia coronaria (53,1%). Sessenta (76%) pacientes estavam em classe funcional III e 10 (12,6%) em classe funcional IV. Cinquenta e oito (73,4%) pacientes foram submetidos a revascularizacao do miocardio concomitantemente. A mortalidade hospitalar foi de 5,1% e teve incidencia maior nos pacientes com idade acima de 60 (12%) anos, em classe funcional IV (20%), com ma funcao ventricular (FE 25 - 14%) e lesoes coronarias triarteriais (10%). Estes fatores tambem estiveram associados a complicacoes cardiacas com baixo debito e uso de BIA. Outros fatores de risco citados na literatura sao discutidos. Os resultados imediatos desse estudo e os resultados imediatos e tardios de outros em que a tecnica usada foi semelhante sao melhores que os obtidos com outros tipos de correcao e sugerem ser este o procedimento de escolha para o tratamento dessa afeccao.

Aneurisma do arco aórtico com fístula aorto-pulmonar: tratamento cirúrgico com sucesso

Aortic arch aneurysm associated with an acute aorto-pulmonary fistula is rare and usually diagnosis is made during the postmortem. Few reports of successful surgical management have been reported and a high mortality rate remains. The authors report on a 78-year-old male patient with an acute aortic arch aneurysm communicating with the main pulmonary artery suffering from cardiac chest pain, hemodynamic instability and lung congestion. The patient underwent surgery to replace the distal ascending aorta, transverse aortic arch and proximal descending aorta as well as fistula closure. The operation was successful.

Unusual presentation of multiple aneurysms of the ascending aorta

At the beginning of the twentieth century, Carrell and Guthrie were the first to use homografts to reconstruct dilated vessels, starting a new era in aorta surgery.1 In 1952, Cooley and DeBakey conducted the first successful ascending aorta intervention without cardiopulmonary bypass in the resection of a sacciform aneurysm by aortorrhaphy.2 In 1956, the same authors performed the first successful replacement of the ascending aorta using cardiopulmonary bypass.3 Since then, aortic surgery has developed quickly because of advances in cardiopulmonary bypass, postoperative care, and surgical techniques that reduce the mortality rates of these procedures.4,5 At present, less invasive techniques, such as endovascular interventions, are performed, especially in thoracic and thoracoabdominal aortic disease, depending on factors such as whether the patients would be at high risk during conventional procedures.6,7 Recent studies and case reports have shown the possibility of performing endovascular procedures in the ascending aorta, which seems to be a promising approach.7 Concerning ascending aorta aneurysms, there are several surgical approaches depending on the level of the disease of the aortic valve, aortic root, sinotubular junction and the ascending aorta. These issues are relevant in the context of congenital diseases such as Marfans syndrome,7 Ehlers-Danlos syndrome,8 congenital aortic valve malformations, and acquired aortic valve diseases.9 It is accepted that apoptosis is the major mechanism for the control of cell density in developing physiological and pathological conditions affecting smooth muscle cells. It was shown that death signals may be triggered outside the cells by cytokine pathways and stress mechanical forces.8 Today, it is known that when there is aortic dilation, there is also cystic medial necrosis. This histological abnormality is characterized by a triad of noninflammatory smooth muscle cell loss, the fragmentation of elastic fibers and the accumulation of basophilic ground substance within cell-depleted areas of the medial layer of the vessel wall, all of which are noninflammatory in nature.9 Medial degeneration does not uniformly involve the ascending aorta.8,9 The convexity of the vessel looks more damaged because of more severe medial necrosis, greater loss of smooth muscle cells and apoptosis and greater elastic fiber fragmentation. These alterations play an important role in the development of aortic aneurysms because they participate in the matrix remodeling process resulting in the synthesis of extracellular proteins such as collagen, elastin, and proteoglycans.8